Human Factors Research Reveals How OR, SPD, and Logistics Shape Surgical Safety

Sterile processing departments (SPDs) are often described in simple terms: Clean the instruments, assemble the trays, sterilize them, and deliver them to the operating room (OR) on time. However, a new human factors study suggests that the reality is far more complex and that understanding this complexity is essential for improving patient safety and infection prevention systems.

Researchers working with the Embedded Human Factors and Clinical Safety Science Unit in the Department of Anesthesia and Perioperative Medicine at the Medical University of South Carolina (MUSC) examined how sterile processing functions within a broader hospital work system. The goal was not to focus on individual errors but to understand how the system itself shapes daily work and how that affects safety for both patients and care teams.

For infection prevention and control (IPC) professionals, the findings highlight a critical reality. Instrument reprocessing and surgical readiness depend on tightly connected systems that span departments, personnel, and even external logistics networks.

A System Supporting Surgery

According to Gabe Segarra, research program coordinator and first author of the study, the motivation behind the work was to better understand the system that supports surgical care.

“The sterile processing department is really important to the hospital as a whole, particularly to the surgical department for a lot of different reasons,” Segarra told Infection Control Today^® (ICT^®) in an interview. “They have to provide the right instruments, keep them clean, keep them organized, and get them to the patients they need to get to.”

Segarra explained that sterile processing is essential to surgical care but is frequently misunderstood because its work occurs largely behind the scenes.

“People might try to say that sterile processing is simple, that all you have to do is clean the instruments, put them in the right trays, and get them to the right patient on time,” he said. “Those things may sound simple on the surface, but they really are not.”

Mapping a Complex Work System

The research team used a systems engineering framework known as the Systems Engineering Initiative for Patient Safety (SEIPS) model. The model helps researchers analyze complex health care work environments by examining interactions among people, processes, tools, and organizational structures.

To gather data, researchers conducted interviews with frontline staff and organizational leaders, performed on-site observations, and worked with multidisciplinary teams to synthesize findings.

“We interviewed professionals from the work environment, both leaders and frontline people,” Segarra said. “We also did in-person observations of the work being done. I went down there and watched people work and asked questions about how things function.”

Researchers also returned to staff members to validate their findings.

“We know we are not the experts. The people doing the work are the experts,” Segarra said. “So it was important to us to verify with them. Does this look like what you do? Are we missing anything?”

Three Pillars of Surgical Readiness

The analysis revealed that sterile processing cannot be viewed in isolation. Instead, the system supporting surgical care depends on three interconnected components.

“The three main parts we identified were the sterile processing department, the operating room, and the courier network that delivers instruments between them,” Segarra explained. “None of them can function correctly without coordinated input from one another.”

For IPC professionals, this interconnectedness has important implications. Problems with instrument availability, contamination control, or workflow delays may not originate within SPD exclusively but may arise from interactions across departments.

“A lot of times people think a particular issue is just a sterile processing problem or an operating room problem,” Segarra said. “But when you look closely, people across the process are helping each other and affecting one another, and it is very complex.”

Adaptation and Real-World Workflows

Another key finding involved the gap between policy and real-world practice.

Segarra noted that staff may often adapt procedures to keep the system functioning, especially when facing operational constraints.

“Someone in leadership might say the process has to be done in this exact way,” he said. “But what we often found is there are many adaptations happening so people can actually get the work done, especially in emergency scenarios.”

For infection prevention teams, recognizing this distinction between policy and practice may be essential when designing improvement strategies.

Researchers often describe this gap as the difference between “work as imagined” and “work as done.”

“We can talk all day about how we think work is happening,” Segarra said. “But until we go see how it is actually happening and try to represent it, that is more challenging. With a human factors approach, we can help leaders and workers find ways of doing things that will work best for them and for patients.”

Implications for Infection Prevention

The study suggests that systems engineering tools could help hospitals better evaluate workflow changes, instrument tracking strategies, or sterilization processes.

“If we understand the system better before we try a new idea, we can look at how a change might affect other parts of the system and be proactive,” Segarra said.

For infection prevention professionals, this systems perspective may also help address recurring challenges such as tray errors, instrument availability, and communication gaps between the SPD and surgical teams.

Elevating the Voices Behind the Work

Segarra emphasized that one of the most important aspects of the research was highlighting the expertise and resilience of frontline staff in the OR, SPD, and courier network.

“These are people that are very skilled at what they do, and they work very hard,” he said.

The research team also collaborated with experts from Clemson University and The Ohio State University and received federal funding from the Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services, to support the project.

Ultimately, Segarra hopes the work will help bring greater attention to the systems that support safe surgical care.

“There are so many things that support surgery beyond the surgeon and the operating room,” he said. “All of these people do so much every single day to make this system work and ultimately keep patients safe.”

Reference

Segarra GC, Catchpole K, Rayo MF, Hegde S, Jefferies C, Woodward J, Taaffe K. Revealing complex interdependencies in surgical instrument reprocessing using SEIPS 101 tools. Appl Ergon. 2024;119:104307. doi:10.1016/j.apergo.2024.104307